The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction

Abstract

Background: The previously described ''perfusion zones'' of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a ''perforator angiosome'' is thus explored. Methods: A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators. Results: Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented. Conclusion: The ''perforator angiosome'' is dependent on perforator location, and can mapped individually with the use of preoperative imaging.

Deep inferior epigastric perforator flap: An anatomical study of the perforators and local vascular differences

“…The medial row perforators routinely cross the midline to perfuse the medial parts of the contralateral hemiabdominal wall and have more extensive branching and larger caliber vessels than lateral row perforators. [17][18][19][20][21] Analyzing the vascularization of the horizontal parts in zone I, we found the best vascularization in the middle 1/3 part. Also, we found the perforators with the largest diameter in this part (region 5).…”

“…However, as with most perforator flaps, an individualized approach to ensure accurate intraoperative mapping and reliable harvest of the flap dependent on the variability of the given perforator must always be carefully observed. 18,31 Further investigations of these finer vessels both in cadavers and preoperatively will enhance our understanding of vascular anatomy of the lower abdominal wall and reduce surgical complications such as fat necrosis and partial flap loss. 32 …”

“…15,16 Until recently, the Hartrampf perfusion zones were standard for selection of the DIEP flap tissue, but more recent studies show that the establishment of zoning is somewhat complex and contradictory. [17][18][19][20][21] We used the gelatin injection technique to define the vascular anatomy of the lower abdominal wall parts. Limitation of these cadaveric studies is inability to mimic physiological conditions, vasoconstriction and physiological shunting.…”

The Anatomical (Angiosome) and Clinical Territories of Cutaneous Perforating Arteries: Development of the Concept and Designing Safe Flaps

“…5. Computed tomography angiography is one of the latest methods that has gained popularity in detecting cutaneous perforators preoperatively, and it is discussed by Rozen et al 2 with great success. This method of identifying large adjacent perforators, connecting them together in the flap axis, and transferring them as a free flap, with 100 percent success in their series of over 100 patients, again confirms the validity of the definition of the clinical territory of a cutaneous perforator.…”

Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction

“…Additionally, it is possible that the ACTUAL planned flap then be assessed on the same scan, and the optimally vascularized volume out of the total volume be estimated. 19 In addition to increasing patient preoperative peace of mind by better predicting postoperative esthetic results, we think that an accurate preoperative estimate of the flap's volume, in addition to radiographically imaging the perforators, their course, and their caliber, may help guide the intraoperative plan. Preoperative knowledge of flap volume may decrease time spent intraoperatively, sequentially trimming tissue for a better flap fit into the breast pocket.…”